There are few specific mental health services for
pregnant women and new mothers. But the need is there, finds Andrew
Mickel
Given the range of professionals who come into contact with
women during and after pregnancy, it is incredible to think that
their mental health needs are being overlooked. But according to
research from Coventry University, many professionals think that is
exactly what's happening for the estimated one in six women who
suffer mental ill health either during or after pregnancy.
There are some dedicated perinatal services around the country,
but in many places, the work is left to generic services. Maureen
Brown, the associate head of midwifery at Coventry University who
worked on the research, says they can't be expected to meet the
complex and specific needs of new and expectant mothers.
"The [mental health disturbance] may be new or it may be
exacerbated," she says. "Anything could cause you to be disturbed -
it could be about your body image being altered by your pregnancy.
For some women it could be about having a being inside them which
is alien to them which they have no control over. You need a
specialist team who understands those mental health issues."
Building effective support
Building up effective support is complex. Frontline
professionals need to know how to identify those women who need
extra support, and what services there are to refer them on to.
Perinatal mental health specialists need to be in place to provide
the services they need in the community. (While the term
'perinatal' conventionally refers to the period around the time of
birth, mental health teams may help a mother for up to a year after
birth.) And for the most serious cases, access to mother and baby
units allows a mother to stay with her child with both psychiatric
and nursery support on hand.
A
national
survey in 2005 by the Royal Society of Psychiatrists found that
only a third of surveyed trusts had dedicated perinatal
multi-disciplinary teams. The university's research showed a
similar mixed picture - while there was a dedicated perinatal
mental health team in Coventry, in the rest of Warwickshire (the
county that Coventry falls under) women would be referred back to
GPs or to mother and baby units, according to Brown.
Theresa Xuereb, the consultant psychiatrist who leads Coventry's
team, which consists of her in a part-time role and two community
psychiatric nurses, says: "We've limited resources so we can only
help those with severe needs, not normally those with mild
ones."
Xuereb adds that there are difficulties in referring to mother
and baby units, and that it is "almost impossible" to refer to
nearby Birmingham, albeit with other options in the Midlands.
Although there are now 19 mother and baby units in the UK, they are
not evenly distributed - there are none, for example, in Northern
Ireland.
Additionally these services are often over-subscribed and can be
difficult to refer in to. Peter Thompson, programme manager for the
Royal College of Psychiatrists' quality network for perinatal
mental health services, says that some units need to be better
publicised: "You hear stories of how frontline practitioners
haven't heard of them and mothers have been put in inappropriate
places. Nice [National Institute for Clinical Excellence]
guidelines don't say much about inpatient services. Many people
would argue that there aren't a lot of beds nationally, and that
they aren't very well spread."
Coherent structure
With national guidance on service provision thin on the ground,
it takes a local focus to get effective support networks up and
running. Northumberland, Tyne and Wear NHS Trust has a six-bed
mother and baby unit to serve North East England and Cumbria, and a
local perinatal mental health team with a dedicated psychiatrist
and six community psychiatric nurses. Angela Walsh, the
psychiatrist there, is now trialling the expansion of the team into
Northumberland, which used to be part of a separate trust.
Pulling together the different services into a coherent
structure has helped mothers but it has taken effort to make the
connections, she says. "Management agreed to join it up. Before, I
was working in just the mother and baby unit and the community team
had to work without a dedicated psychiatrist.
"And there were no specialised nurses there [in Northumberland]
- they used to refer directly to community mental health teams
instead. There used to be an outpatient clinic there once a week,
but it couldn't access specialist teams."
Walsh says she now aspires to set up a full clinical network, to
have mental health and maternity teams working tightly alongside
each other. That is something that has happened in just a handful
of locations in the country so far, despite joint working being
flagged in a
2004 children, young people and maternity services National Service
Framework as necessary to improve provision.
"Now, we do work very closely with maternity services," she
says. "We take pregnant women so we have to work very closely -
community teams, health visitors and midwives can refer directly
into us."
Knowledge gap
The knowledge of those frontline practitioners is another area
which needs more work, according to Coventry University's research.
This is one area where there is specific national guidance. Nice
specifies three questions which staff should ask pregnant women to
assess their mental health status: Have you felt down, depressed or
hopeless during the last month? Have you been bothered by having
little interest or pleasure in doing things? Is this something you
feel you need or want help with?
Gail Johnson, the education and professional development advisor
for the Royal College of Midwives, says: "It's hard to monitor
everyone but there's an expectation to do it. It's a start and
we've got to be asking those questions - if we're doing that, then
it also shows the problem is common and women don't think there's
now stigma."
But Brown says this isn't the picture on the ground in Coventry
and Warwickshire because midwives know there isn't necessarily
somewhere to refer them on to, so don't ask the questions.
"Health visitors, on the other hand, do [ask the questions] and
use a questionnaire to measure the response to find out if a woman
is postnatally depressed."
While the keen attention of health visitors is welcome, all
frontline practitioners need to understand these disorders because
making the right connections between maternity and mental health
services is vital if women are to receive appropriate perinatal
support.
HOME START HELPS FILL THE GAP
With many specialist services over-subscribed, some third sector
organisations have sprung up to help those with lower levels of
need.
Beth Jenkins gave birth to Alexander in 2006 and says: "I
realised I had post-natal depression when I burst into tears for no
reason whatsoever," she says. "Part of me told myself I was just
being daft but it was the emotional part of me that just took
over."
Her GP put her on anti depressants after confirming that she did
have post-natal depression and her health visitor put her in touch
with Home Start, a network of volunteers who support parents who
are struggling to cope for various reasons, including post-natal
illness.
After talking to a community mental health nurse Jenkins decided
she only needed day-to-day help rather than intensive services. Her
assigned volunteer, Dorothy, helped with minor tasks like putting
out the washing or guidance on where to go swimming.
"The most important thing is for someone to be there and talk to
you. Dorothy didn't only care about Alexander, but about me too and
she checked how I was doing," she says. "It gives you your
self-confidence back and reinforces that you can do well."
This article is published in the 7 May 2009 edition of
Community Care under the headline "Pregnanat pause"